The authors describe their experience in carrying out clinical and pst’chohiological research in a therapeutic milieu setting. The clinical-research meeting. composed ofclinical-care staff with secondary research responsibilities, researchers, and acute/v psvchotic patients. proved to he a useful mechanismfor identifying and resolving inevitable problems at the clinical-research interface and enhanced the effectiveness of research implementation andpatient care. The authors discuss three specific areas where covert issues threatened to undermine the work ofthe unit-the abrogation of research responsibility, the abrogation of clinical responsibilitt’. and in tergro up competition and en vt.
INPATIENT PSYCHIATRIC units organized around intensive biological investigations of relatively few subjects have become exceptionally fruitful for the study of psychoses. Despite, and partly because of, high staff-to-patient ratios, these units have major problems at the interface of clinical care and research. Epstein and Janowsky ( I ) and Reich and Weiss (2) have maintained that these units operate under the pressure of conflicting priorities. This is illustrated by the withdrawal of a successful medication because of a double-blind protocol. Bressler and associates (3) have raised the question of the traumautic input of an experiment on a subject and the clinical responsibility of the researcher to not harm his patient. Redlich and Brody (4) and Denbar (5) have drawn attention to the unconscious determinants of the behavior of the researcher. They have implied that, like the therapist, the researcher may unknowingly be antitherapeutic in his work but, unlike the therapist, he does not have the safeguard of the clinical team with which he works. Crandall and associates (6) have stressed the importance of successful collaboration between researcher and clinician in order that both may effectively perform their work. Despite the growth that occurs in both the research and
At the time this work was done, Drs. Sacks and Fink were Clinical Associates, Psychiatric Assessment Section, Adult Psychiatry Branch, National Institute of Mental Health, Bethesda, Md., Dr. Carpenter is Acting Chief of the Section. Dr. Sacks is now Assistant Professor of Psychiatry, New York University Medical Center, and Director of Residency Training, Veterans Administration Hospital. First Avenue at East 24th Street, Rm. l7021-W, New York, N.Y. 10010. Dr. Fink is Assistant Professor of Psychiatry, Division of Biological and Medical Sciences. Brown University, and Chief, Acute Day Hospital. Butler Hospital, Providence, RI.
clinical staff when they work well together (7), it may be difficult for the two groups to collaborate successfully (I 4, 6-8). Some authors (I, 8) have maintained that an independent consultant is required to mediate disputes between the research and clinical staff. On the other hand, Reich and Weiss (2) have concluded that running a suecessful research ward in a therapeutic milieu setting may well be impossible. In this paper we describe our experience in carrying out clinical and psychobiological research in a therapeutic milieu setting. A specific mechanism, the clinical-research meeting, was designed to facilitate the identification and resolution of problems at the clinical-research interface. Based upon 3 years of experience with this meeting, we will discuss several intragroup and intergroup phenomena that enhance or impede the work of this meeting. -
The unit was designed to investigate acutely psychotic patients from a variety of clinical, phenomenological, biochemical, and physiological perspectives. A clinical program was established to treat psychotic patients in a therapeutic milieu with the maximum utilization of psychosocial and psychodynamic techniques. Self-understanding was defined as therapeutic, and multiple individual and group interactions were directed toward this goal by the clinical staff. The research was investigative, not therapeutic, and the patients were told that therapeutic gain does not result from research procedures. Rather, it was made explicitly clear that the patients were expected to participate in the research investigations as an aspect of their involvement with the unit, where they received psychiatric evaluation and treatment without cost. The maximum period of hospitalization was 18 weeks, and patients were discharged earlier as warranted by their clinical status. The usual census was 7 to 10 patients. Psychotic patients between the ages of 18 and 60 were admitted to the unit. The criteria for admission were the presumptive diagnosis of schizophrenia; the conspicuous presence of such symptoms as delusions, hallucinations, bizarre behavior, and formal thinking disorders; and adequate occupational and social functioning when not psychotic. Medication was stopped at the time of admission but was occasionally used during the middle phase of the patients’ treatment. This permitted drug-free testing periods early and late in the hospital stay. A high staff-
patient ratio permitted greater use of psychosocial therapeutic techniques and enabled agitated patients to remain more consistently involved in the milieu. The patients in this clinical program generally recovered; that is, they became nonpsychotic and were able to resume their social and occupational functions (9). This clinical research unit was set in the Clinical Center of the National Institutes of Health. The nursing staff consisted ofa head nurse, 4 other registered nurses, and 8 to 1 1 nursing assistants who provided shift coverage of 4 to 5 people during the day, 3 to 5 in the evening, and 2 to 4 during the night. The primary role of the nursing staff was clinical care; in addition, they assisted in the collection of research data including biological specimens and daily behavioral ratings. The medical staff consisted of 3 junior psychiatrists (clinical associates) whose roles ineluded the clinical care of patients, frontline administration of the unit, and research collaboration. A senior staff psychiatrist had overall responsibility for establishing and directing the clinical and research programs. As such, some staff members wore two hats simultaneously and/or changed them depending on issues and group process. In this paper the term “clinical staff” will be used to refer to all of these nurses and doctors, albeit equivocally to the senior psychiatrist. The term research staff” will refer to a variety of collaborating researchers and research assistants who had no clinical responsibility and to the medical staff already listed, albeit equivocally to the clinical associates. “
The clinical-research meeting, chaired by the psychiatrist with overall responsibility for the clinical-research program, met for I hour each week. The membership was composed of all patients, all clinical staff on duty, all research staff based on the unit, and representatives from several collaborating laboratories. The tasks of the meeting were 1) to identify, illuminate, and resolve issues at the clinical-research interface, and 2) to enhance the effectiveness of research implementation. Examples of the first task were to recognize the manner in which research tasks impede or facilitate clinical care; learn of patients’ experiences and ideas emanating from their being subjects under investigation; deal with complications arising from actual and fantasized research endeavors, ranging from the unpleasantness of dietary control on a metabolic unit to distorted ideas about malevolent intent of urine collections and informed consent (10). Examples of the second task included the introduction of new protocols, evaluation of the current success of data collection, resolution of logistical problems of research scheduling, and presentation of research results. Each staff and patient at the meeting had the responsibility to identify relevant issues, provide information, and contribute ideas toward understanding and resolving clinical-research problems. For example, a staff member might question whether a patient could be managed off the unit for a particular investigation or a researcher
could question why there had not been successful participation in a protocol. Because the membership comprised all of the people involved in the clinical-research operation, the necessary information relating to these problems was obtainable and decisions aimed at their resolution could be taken. Patients were expected to provide information regarding their ideas, experiences, and fantasies about the research. They often made inquiries before and after the research concerning the effects of their participation in a research procedure. For example, following an investigation that involved a lumbar puncture, patients asked questions that had not been anticipated and which patients to be studied were fearful of asking. Thus their belief that this procedure revealed their secret thoughts or that the removal of cerebrospinal fluid caused their brains to shrink could be openly discussed. By this process in which patient-subjects reported and inquired about their research experiences, participation was fostered, informed consent became a more meaningful process, and the clinical and research staffs learned more about the psychological significance of the research to the patients. This was important to the clinical staff in their treatment programs and to the research staff when they evaluated their data ( I I).
The clinical-research meeting had many attributes, and both its accomplishments and problems were noteworthy. During the 3-year life of this meeting, we were pleased with its economy for doing work, e.g., enhancing patient participation, providing a setting for an effective informed consent process, permitting early recognition and resolution of problems, reducing the amount of time required by leaders to become informed and reach decisions, and facilitating intergroup access. In this paper, however, we will focus on those problem areas where coyert intragroup and intergroup issues threatened to undermine the avowed clinical and research work tasks. These three areas-the abrogation of research responsibility, the abrogation of clinical responsibility, and intergroup envy and competition-were chosen because they are critical issues and are relevant to units with dual (clinical and research) missions. Throughout the following discussion, the reader should remember that the membership of the clinical-research meeting consisted of three relatively distinct groups: patients, clinical-care staff, and research staff. The patient group was clearly defined, and the patients’ primary concern was their treatment, but they all accepted the responsibility of participating in the research program. All of the clinical-care staff had secondary research responsibilities, but only a few of the researchers also had clinical-care duties. Distinction between groups was blurred only insofar as the members of the medical staff belonged to both staff groups, with their primary identification depending on the content of a particular issue.
There was ample evidence that the patient, clinical, and research groups did not feel fully comfortable with the research tasks of the unit. This was especially obvious early in the program. For example, a researcher asked the clinical staff whether a project was feasible considering the severe symptoms of many of the patients. Instead of responding, the clinical staff directed this question to the patient group. The patients, in turn, responded with either silence or disruptive behavior that interrupted the work of the meeting. This distraction prevented further discussion and implicitly provided a negative answer to the researcher’s question. In this example, the behavior of all three groups suggested their anxiety regarding the use of patients as experimental subjects. Under the guise of reasonable inquiry, both the research and clinical staff had abrogated their responsibility for research decisions. The patients, through their behavior, had refused to accept it; in addition, through their disruptive behavior they forced clinical management to supersede research planning. In this example, no one accepted responsibility for research decisions. Kubie(l2) has commented on the guilt that accompanies a scientist’s research, especially when he relates to patients primarily as experimental subjects. Unlike the doctor-patient relationship, the research relationship may yield little or no therapeutic advantage to the patient but may be of considerable importance to the researcher in the success of his research and the advancement of his career. This may lead the members of the staff to doubt their clinical competence and to feel that they are exploiting the patients. Another example of abrogation of research responsibility can be seen in the lack of attention to patient nonparticipation. Often, failure of a patient to cooperate in research was clearly irresponsible. Here we are not referring to the patient’s hesitancy to take an experimental medication but to behavior such as putting cigarette butts in the urine specimens or regular failure to collect urine samples. The members of the clinical staff were skilled in understanding and resolving an issue such as a patient hiding under his bed during group therapy. However, they might fail to note or explore a patient’s lack of participation in research. The research staff at times manifested this same irresponsibility by hesitating to question patients and clinical staff about problems in research participation. It was only after considerable exploration of these activities over many months that all of the members of the clinical-research meeting began to recognize their collective responsibility for the successful accomplishment of the research. The patients began to realize that their thoughts and feelings about the research were as valued as their participation and, in many instances, led to changes in the program. As collaborators, they began to work with newly admitted patients in identifying common anxiety-provoking fantasies about the research that were often untrue or misleading. The members of the clinical staff gradually became less defensive when the failure to complete research protocols was discussed, and
they also became more autonomous and responsible for instituting measures to ensure successful research participation. The research staff became less “apologetic” as problems at the clinical-research interface were defined and explored. The clinical and therapeutic potential of such collaboration became obvious, but it was only after 1 ‘/2 years that the so-called “research meeting” began to be called the “clinical-research meeting.”
The staff’s attempts to disavow responsibility in their complex research roles had its parallel in the clinical area. The clinical-research meeting proved to be a setting in which to examine the problem of the abrogation of clinical responsibility by the clinical staff and the assumption of this responsibility by the researchers. For example, at times the staff members viewed the research procedures as the cause of clinical problems, and they therefore expected the research staff to be responsible for their resolution. In other situations the clinical staff devalued clinical care by maintaining that they were working on the unit simply to watch over the patients while the research was conducted. The research staff often yielded to the temptation to assume clinical leadership. For example, a patient asked a “scientific” question about schizophrenia. To everyone’s relief, a researcher answered eloquently, and no one pointed out that this transaction was aimed more at mutual gratification than at information. The entire group ignored the fact that understanding and responding to patients’ communications about mental illness was within the expertise of the clinical staff. Abrogation of responsibility in the dynamic sense described here is commonplace, of course. What was important was that the clinical-research meeting provided a mechanism for recognizing and modifying this behavior when it occurred. A poignant example of this process occurred when a young, single female patient asked if the genetics of schizophrenia were being researched. The research leader inquired as to why the patient was interested in this question. It was then learned that the patient had asked several clinical staff members whether her illness was inherited, and if so, whether she could marry and have children. Th4e clinical staff had not explored this deeply personal question with the patient because it had been labeled as a research question about genetics. The clinical staff members understandably had attempted to avoid the discomfort that such an exploration might produce. In the clinical-research meeting the clinical significance of this issue quickly emerged, and leadership in dealing with it was appropriately assumed by the clinical staff.
Intergroup brief, almost
were regularly comments that
criticism. The accusatory quality of these remarks was apparent when an angry member of the research staff stated that it was cruel to keep a patient in seclusion or when a clinical staff member implied that the research leadership did not care about what happened to people as long as they got their data. Patients often exploited this split. These negative intergroup interactions were usually precipitated by a recognizable frustration (e.g., inadequate numbers of nursing staff or failure to report a malfunctioning freezer where biological specimens were stored). But an undercurrent theme emerged so regularly that it was eventually made explicit and acknowledged: reciprocal envy between three competitive groups. The research staff manifested a considerable interest in clinical functions. This was especially true for those research members who did not have clinical backgrounds. Research staff often showed disdain toward clinical management decisions. They would offer suggestions that seemed eminently reasonable but were maddeningly simplistic to clinicians. When such ideas were eloquently presented by research leadership, they often had the effeet ofshaking the clinical staff’s confidence. It would appear that if only the clinical staff members were bright enough, they would be able to treat patients with ease. Patients would aggravate this blow to the clinician’s selfesteem by manifesting a decided interest in the researcher’s idea or being unusually responsive to his instructions. A screaming patient might suddenly fall silent when a researcher suggested that he “be quiet and let others talk.” The patient might go so far as to express appreciation for the suggestion, as though it were novel. Such a situation illustrated the researchers’ competitiveness, the clinicians’ envy of the researchers’ presumed effectiveness and authority, and the patients’ exploitation of the split. A more detailed example will illustrate these themes as an intergroup phenomenon. During one clinical-research meeting, a nonphysician researcher from a collaborating laboratory suggested that increased sensitivity to each other’s problems could be gained if a research member lived on the unit for a few days. At first this suggestion sounded reasonable, and many were surprised when clinical staff members vigorously objected as though they were to be watched and evaluated. As the researcher argued his position, he received support from the patient group. The nature of their support made one feel that opposition to this humane endeavor could only be based on paranoia unless, of course, the clinicians were being negligent and cruel and did not want this discovered. Goffman (13) and Caudill (14) have given examples of the wisdom of such a plan. This meeting ended without resolution, and further exploration in two subsequent meetings revealed the following information. First, the idea of a researcher living on the unit had originated with a patient who suggested it to the researcher while participating in an experiment. This patient had been accusing the clinical staff of cruelty for several weeks. The idea, then, was not to increase awareness between groups but rather to have the research staff apprehend the clinical staff in wrongdoing. Second, the
researcher who introduced the proposal had himself in mind as the person to carry out this mission. His personal investment in this plan became clear, and he acknowledged his wish to share in the “fascinations” of ward life. Here, as in many other instances, members of the research staff struggled with a profound desire to be therapeutically involved with patients, and they felt that their own work-life was, by comparison, more prosaic. Third, the clinicians noted their envy of the researcher’s apparent organization and competency. They contrasted their bewilderment over clinical issues to the ease with which the research staff could cope with complex material. The researcher seemed able to take the most complicated data to his computer for quick and certain answers. Thus in this situation we found that members ofthe research and clinical stall were envious, suspicious, and competitive with each other. The patients often participated in the staff splitting described earlier. They frequently expressed envy of the staff’s ability to function maturely and competition was seen regularly in patient behavior that seemed to mock or scorn the more mature aspects of stafi functioning. The patients’ envy of the staff was fully reciprocated. Many members of the staff realized from time to time their wish to deal with the baffling, unending demands of the unit’s work by becoming irresponsible and nonsensical. Furthermore, they often regarded the exciting mental activity of the patients as being preferable to scoring rating scales, preparing protocols, and other aspects of their work.
In this paper we have described a meeting that was useful in focusing on and resolving the difilculties that arose in functioning at the clinical-research interface. The difficulties included not only the administrative and tactical problems of a complex work situation but also the more profound covert issues that may totally undermine the organization. We have defined three such issues, as follows: the abrogation of research responsibility, the abrogation of clinical responsibility, and intergroup competition and envy. These issues are precisely what might have been expected in a unit that consisted of patients, clinicians, and researchers, each of whom had his own work and responsibilities. Intergroup conflicts in such a situation are inevitable, but our findings suggest that they need not be detrimental to either research or therapy. In fact, the exploration of such conflicts and a constant vigilance against them seem to foster greater success in each of the respective endeavors. For the researcher, this meeting has increased the success of his research efforts by identifying and solving problems that otherwise might have covertly undermined his investigation (16). For the clinician, the patient’s behavior and thoughts regarding research have
Searles(I5) has described the scorning behavior of schizophrenic patients in psychotherapy as a defense against their fear of being disappointed by an adored and idealized therapist and their envy of him.
become a valuable source of information in the evaluation of the patient’s clinical problems and status. And finally, for the patient the meeting has provided an opportunity for a rewarding and meaningful collaboration in the organization and evaluation of the research projects in which he is the subject. We have found that the clinical-research meeting is an extremely useful structure in accomplishing the complex tasks of treating and investigating acutely psychotic patients.
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